Q&A: Reporting psychotherapy with interactive complexity

Q: When would it be appropriate to report CPT® add-on code 90785 (interactive complexity)?

A: Interactive complexity refers to specific communication factors during a visit that complicate delivery of the primary psychiatric procedure. It’s reported using add-on code 90785 after a primary CPT code for one of the following services:

• Diagnostic psychiatric evaluation
• Individual psychotherapy 
• Group psychotherapy

Per the CPT guidelines, interactive complexity may be reported when at least one of the following communication factors is present during the visit:

• Emotional or behavioral conditions inhibiting the treatment plan
• Evidence or disclosure of a sentinel event that the therapist is mandated to report to a third party (e.g., abuse or neglect with report to state agency)
• Maladaptive communication
  • High anxiety
  • High reactivity
• Repeated questions or disagreement
• Use of interpreter or translator services to overcome barriers to diagnostic or therapeutic interaction with a patient
• Use of play equipment (e.g., toys, dolls, physical aids)

The medical record should detail adaptations utilized in the session, rationale for employing these interactive techniques, and treatment recommendations.

Editor’s note: Stephanie Moore, CPC, CPMA, answered this question during the HCPro webinar, “Master Outpatient Behavioral Health Coding and Documentation.”

This answer was provided based on limited information submitted to JustCoding. Be sure to review all documentation specific to your own individual scenario before determining appropriate code assignment.